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Mr. Bercow: I am sure that the hon. Gentleman would not chunter on about primary care groups without first troubling to do his homework on their cost. Will he tell the House what he estimates to be the additional annual cost to the NHS budget that is created by the establishment of primary care groups?
Mr. Lewis: We are talking about significantly reducing bureaucracy, and devolving power and resources from health authorities down to GPs and the people who are closest to patients. It is nonsense to talk about extra costs when the policy is designed to reorganise the way in which money is spent in the health service and to ensure that it is spent more cost effectively and as close to the patient as possible. There can be no doubt that the overall objective of the Labour Government's health reforms is to achieve a significant reduction in the money spent on bureaucracy, which will allow money to be redirected to patient care.
Mrs. Marion Roe (Broxbourne): Rationing exists in the national health service. In a cash-limited system, it cannot but exist and it is sheer folly to suggest that it does not. Rationing has existed since the health service began, with general practitioners controlling access to services and treatments, and hospitals manipulating their waiting lists. Demand has always outstripped resources and provision. The words spoken in the House by the Minister for Public Health when she said that rationing simply does not exist within the NHS must hang heavily, like an albatross around her neck. The Health Committee, of which I was Chairman for five years, recognised the existence of rationing in its inquiries into priority setting in the NHS. It produced reports on the drugs budget and on purchasing in 1994 and 1995, so this is not the first time that such issues have been debated.
The Conservative Government recognised the bottomless pit of demand and used the reforms of the 1990s to address it. They created a fundholding system that put GPs at the centre, providing care for a population they knew. It enabled GPs to set priorities and to identify those in greatest need, and so provided a bespoke health care service that was sensitive to the individual. Resources could be used flexibly and cost effectively, so many more patients could receive care. As a result of Conservative policy, many more staff were employed. The Conservative Government concentrated on waiting times, not on waiting lists, and in less than four years, they reduced from more than nine months to less than four months the average time that patients had to wait before being admitted to hospital. Sadly, that good work is being undone and patients now wait ever longer for admission.
We now have a Government who, with the greatest respect, are deceitful and duplicitous: they deny that rationing exists while taking steps to conceal the shortcomings of their own policies. There is cynical manipulation of patients through the waiting list money being hurled at the system by the Secretary of State. Waiting lists are the tap that turns health care on and off, but under the current system, there is no logical method for selecting patients from the waiting list. Managers rearrange cases so that if the Government want a number of patients treated, they get that number of patients treated, often without consideration being given to the severity of patients' condition or the distress that failure to be selected may cause.
A facile scattergun approach has been adopted--one that takes no account of the time that people spend waiting and fails to recognise that need should be the key determinant of care. In the pool of patients waiting to be fished out for treatment, Government initiatives encourage the rescue of those in shallow water--the patients most easily treated, who occupy a bed for the shortest time--to ensure rapid turnover. The patients in the deepest water are often left longest and some drown while waiting.
How have the Government approached the problem of infinite demand and finite resources? They have come up with primary care groups, which are a rag bag of ideas, hastily cobbled together. They force GPs to relinquish personalised care and give up valuable clinical time to undertake management roles for which they are neither trained nor enthusiastic. They are inadequately funded,
rely on good will for their operation and are supplied with a mass of guidance--often contradictory--within which to operate.
Let us take health service circular 1998/139, entitled "Developing Primary Care Groups". Paragraph 52 states:
Paragraph 53 states:
Only a confused Government bent on folly could believe that rationing could be abolished and money saved by fragmenting the service, destroying management and delegating the operation of the system to inexperienced doctors. Already the evidence is beginning to appear. The Government suggest that inequity must be tackled by levelling up, but what is really happening? The first decisions made by fledgling PCGs are to scrap in-house clinics to save money and to reduce GP practices' drug budgets to save money. That is not levelling up; it is dumbing down.
Survey after survey of medical professionals shows conclusively that rationing is preventing patients from getting the care they need. Only last week, a survey in Doctor magazine revealed a damning indictment of the Government's policies and made a laughing stock of their denials. Of respondents, 97 per cent. believe that rationing is inevitable, 79 per cent. say that services or treatment have been withdrawn and 20 per cent. said that patients had suffered as a result of rationing; most serious is the fact that one in 20 said that patients had died as a result. In my constituency, infertility treatment is a thing of the past, plastic surgery is extremely difficult to obtain and even hip pain is no longer an indicator for a joint replacement.
We do not need denials of rationing: we need a fair and effective mechanism for managing rationing. We need mature debate, not meaningless rhetoric. We do not need the Government's retreat to the magical, mystical modernisation fund which they claim will do so much, yet has been spent five times over in successive health circulars. The health professions recognise it and the public accept it: the evidence is clear. When citizens' juries, focus groups and individuals are presented with the facts, they can understand complex medical and case-mix issues. They can arrive at sensible decisions about who gets what.
Rationing is not a job for managers: they do not have the knowledge and it invites public disapprobation. GPs may be the best option, but they are increasingly
uncomfortable with that demand. The Doctor magazine survey showed that 80 per cent. of doctors recognise that rationing is a cause of friction between them and their patients. Increasing complexity makes decisions more difficult, and many doctors say that that is not why they entered the medical profession. Other GPs may use rationing as a political tool. It would not be difficult to break the bank and stay within ethical and contractual responsibilities.
Mr. Dawson:
Why should the term "rationing" be used in relation to the health service when it is applied to no other area where infinite demand will always be met with finite resources? Does not "rationing" have pejorative overtones?
Mrs. Roe:
That word has been used for many years to describe the budgetary dilemmas that certain doctors and hospitals face. We should use the term "rationing" and be open about it. In Health Committee meetings, we used the word "priorities", but we also referred to "rationing" because it meant something to the people who were giving evidence.
"The ability to offer patients the individual care they require has been and remains the cornerstone of general practice. The new system will continue to allow individual GPs to decide what is best for the patient, whether, for example, to prescribe drugs or refer patients to hospitals in the light of their clinical judgment. The freedom to refer and prescribe remains unchanged."
The best bit is:
"Patients will continue to be guaranteed the drugs, investigations and treatments they need".
The Government are clearly saying that there is to be no rationing--but wait, what about the next paragraph?
"Primary care groups will be expected to live within their budgets. Where a group is forecasting an overspend it must work with its host health authority to manage the position in-year".
So, there is to be rationing after all, with guidance telling GPs, "Give patients whatever they need, but don't spend money doing it." What a devious philosophy. We know that more than one third of health authorities are overspent.
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